California Board of Chiropractic Examiners - License ...

BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY ? GAVIN NEWSOM, GOVERNOR

DEPARTMENT OF CONSUMER AFFAIRS ? CALIFORNIA BOARD OF CHIROPRACTIC EXAMINERS 1625 N. Market Blvd., Ste N-327, Sacramento, CA 95834 P (916) 263-5355 | Toll-Free (866) 543-1311 | F (916) 327-0039 | chiro.

REQUEST FOR VERIFICATION OF LICENSURE/CERTIFICATION

Instructions: You must complete all the information requested on this form. Include a check or money order made payable to "BOCE" in the amount of $124.00. Submit this form to the address above. Please allow 4-6 weeks for processing. ATTACH ANY ADDITIONAL FORMS THAT MUST BE COMPLETED

License Information:

License Number: _____________________________

Last Name:

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First Name: _______________________________________________

Address to which the verification of licensure/certification should be mailed:

Entity Name: Contact: Address 1: Address 2: City: State:

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______________________

Postal Code:_____________________________

Signature: Telephone: Date:

______________________________________________ ______________________________________________ ______________________________________________

Rev. 12/18

Receipt No. _____________________ Date Cashiered _________________ Amount Paid ___________________

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